Restaurant workers are a large population at high risk for tobacco use, physical inactivity, and influenza. They are difficult to reach with health care interventions and may be more accessible through workplaces, yet few studies have explored the feasibility of workplace health promotion in this population. This study sought to identify barriers and facilitators to promotion of tobacco cessation, physical activity, and influenza vaccination in restaurants.
Moderators conducted 7 focus groups, 3 with restaurant owners and managers, 2 with English-speaking workers, and 2 with Spanish-speaking workers. All groups were recorded, and recordings were transcribed and uploaded to qualitative-analysis software. Two researchers coded each transcript independently and analyzed codes and quotations for common themes.
Seventy people from the restaurant industry participated. Barriers to workplace health promotion included smoking-break customs, little interest in physical activity outside of work, and misinformation about influenza vaccinations. Facilitators included creating and enforcing equitable break policies and offering free, on-site influenza vaccinations. Spanish-speakers were particularly amenable to vaccination, despite their perceptions of low levels of management support for health promotion overall. Owners required a strong business case to consider investing in long-term prevention for their employees.
Tobacco cessation and influenza vaccinations are opportunities for health promotion among restaurant workers, whereas physical activity interventions face greater challenges. Promotion of equitable breaks, limited smoking-break policies, and free, on-site influenza vaccinations could improve health for restaurant workers, who often do not have health insurance. Workplace interventions may be particularly important for Hispanic workers who have additional access barriers.
The restaurant industry employs a large population of workers who earn low wages and have few health benefits. Restaurants are the second-largest private-sector employer in the United States, employing more than 13.5 million people (
Restaurant workers are at high risk for obesity, smoking, and influenza. A Washington State study of obesity showed that, similar to the average rate among all Washington employees, only 37% of food workers meet minimum physical activity recommendations (
As workplaces, restaurants provide a venue to reach workers and improve their health. The Centers for Disease Control and Prevention’s
The purpose of this study was to identify barriers and facilitators to workplace health promotion among restaurant workers at sit-down restaurants. Secondary aims were to compare perceptions between restaurant owners and workers and between English- and Spanish-speaking workers.
We conducted 7 focus groups in July 2012 with workers at restaurants in King County, Washington. King County has a population of just over 2 million and is 63% non-Hispanic white and 9% Hispanic. King County has a strong public health infrastructure. It is recognized as a leader in eliminating health disparities, and smoking is prohibited indoors and within 25 feet of public places (
We used a convenience sample. A contracted commercial focus group facility (Consumer Opinion Services) recruited all participants through emails to names in databases of previous focus group participants and to industry lists supplied by a regional restaurant trade association. King County has approximately 2,000 sit-down restaurants, and about 3% of King County workers are employed by a sit-down restaurant (
Focus groups were conducted at a focus-group facility in Seattle. One member of the research team (K.H.) moderated the English-speaking groups, and another member (C.A.), bilingual and trained in cultural competency, moderated the Spanish-speaking groups in Spanish. Interview questions were developed to inform a pilot study focused on effective workplace health promotion in a restaurant setting. The interview guides focused on motivations, barriers, and facilitators to offering and participating in workplace health promotion in the areas of tobacco cessation, physical activity, and influenza immunizations. The guide did not distinguish between on-the-job and leisure-time physical activity. At the end of each session, participants completed a brief survey covering demographics and health behaviors.
All focus groups were recorded. Audio recordings of the Spanish-speaking groups were transcribed in Spanish, then back-translated to English (GMR Transcription Services Inc). English-speaking groups were also transcribed (Proof Positive Transcriptions). Transcripts were imported into Atlas.ti (Scientific Software Development GmbH) and were coded and analyzed using thematic content analysis. Initial codes were categorized into higher-order codes reflecting emergent themes. One team member (C.A.) created the coding structure and 2 members (C.A. and K.H.) coded each transcript independently to identify themes, meeting frequently to ensure consistent interpretation of codes. We grouped data by topic area (tobacco cessation, physical activity, and influenza vaccination) and identified barriers and facilitators for each. We chose quotes from restaurant owners (RO), English-speaking workers (EW), and Spanish-speaking workers (SW) to represent central themes; quotes were included only when several participants stated similar ideas.
Seventy people (
| Characteristic | Owners, n (N = 28) | English-Speaking Workers, n (N = 20) | Spanish-Speaking Workers, n (N = 22) |
|---|---|---|---|
|
| |||
| Female | 11 | 9 | 9 |
| Male | 17 | 11 | 13 |
|
| |||
| 18–24 | 0 | 5 | 5 |
| 25–34 | 6 | 8 | 5 |
| 35–44 | 9 | 3 | 3 |
| 45–54 | 6 | 3 | 5 |
| ≥55 | 7 | 1 | 4 |
|
| |||
| <High school degree | 0 | 0 | 6 |
| High school degree or GED | 1 | 4 | 9 |
| Some college or vocational school | 4 | 12 | 4 |
| Degree from vocational school | 3 | 2 | 0 |
| Degree from college or university | 17 | 2 | 1 |
| Graduate or professional degree | 3 | 0 | 1 |
| Missing data | 0 | 0 | 1 |
|
| |||
| Bartender/server | 0 | 13 | 3 |
| Cook | 0 | 5 | 6 |
| Hosting/cashier | 0 | 2 | 1 |
| Dishwasher/preparation work | 0 | 0 | 10 |
| Owner/manager of franchise restaurant | 11 | 0 | 0 |
| Owner/manager of nonfranchise restaurant | 17 | 0 | 0 |
| Missing data | 0 | 0 | 2 |
|
| |||
| ≤10,000 | 0 | 2 | 10 |
| 11,000–20,000 | 0 | 6 | 7 |
| 21,000–30,000 | 1 | 3 | 4 |
| 31,000–40,000 | 6 | 0 | 1 |
| 41,000–50,000 | 3 | 3 | 0 |
| 51,000–60,000 | 2 | 4 | 0 |
| ≥61,000 | 15 | 1 | 0 |
| Missing data | 1 | 1 | 0 |
All participants agreed that smoking among restaurant workers is common and spoke about smoking primarily in the context of smoking breaks. Owners perceived smoking as a disruption to productivity, English-speaking workers focused more on the social context of smoking, and Spanish-speaking workers discussed smoking as something done alone to relax from a stressful job: “I work at a very busy restaurant, and it’s stressful; and I relax when I smoke” (SW).
The most frequently mentioned barrier to tobacco cessation in restaurants was that smoking breaks are the only way to get a work break in restaurants: “Other than if you go to the bathroom, you don’t get a break. You get to go to the bathroom or you get to have a cigarette” (EW).
Another barrier is that smoking is interwoven into the social culture of restaurant workers. Workers said they were prompted to smoke when coworkers smoked: “I mean, if she takes a smoking break, and if you like her, you’re going to smoke with her” (EW). Casual smoking while drinking alcohol was mentioned as a common restaurant habit.
Overwhelmingly, owners agreed that smoking is a private decision, and asking workers to stop smoking would be intrusive. Some English-speaking workers were concerned that tobacco cessation promotion efforts would single out individual smokers.
Owners were interested in reducing the number of smoking breaks. They expressed frustration about smokers taking frequent breaks during work hours and concern about tensions between smokers and nonsmokers caused by the perceived lack of break opportunities for nonsmokers: “The people who smoke are the ones who get the breaks. It’s irritating
Although owners focused more on productivity issues caused by smoking breaks, all groups supported tobacco cessation promotion as an issue that affects the customer experience. The smell of smoke was a strong concern for all groups. Owners suggested limiting the hours during which workers are permitted to smoke while on the job and supported the idea of promoting a smoking cessation quitline to workers indirectly using posters or pamphlets. Owners thought directly speaking to employees about cessation was intrusive.
All groups emphasized the physically rigorous nature of restaurant work, and participants thought that health issues other than physical activity were more relevant to the industry.
Many participants mentioned feeling physically exhausted at the end of the workday and said that they did not have energy to exercise. Long workdays and varying schedules were also common barriers.
When asked to consider offering gym discounts, owners stated that because of high employee turnover, they did not have the luxury to invest in something that would provide only long-term health benefits. Owners and workers doubted that anyone would actually use gyms and said that workers would prefer health insurance or paid vacation: “They want health insurance. They don’t want a gym membership. They want health insurance” (RO).
Participants noted that the constant exposure to unhealthy food at work was more of an industry barrier to better health than lack of physical activity. Workers thought that restaurants promoting physical activity while selling unhealthy food sent an inconsistent message about the importance of employee health: “[Y]ou’re selling fried food and burgers and all that stuff and you’re trying to get me to go to the gym? I’d be like okay, well, do you want to make a better menu?” (EW).
Owners viewed social exercise (such as company sports teams) as a worthwhile investment because it could foster team-building, increase morale, and improve retention: “From a restaurant perspective I would want to see group activities that are team builders. That’s what I would be interested in investing in” (RO).
English-speaking workers emphasized that restaurants have a tight-knit social culture and thought company teams would be appealing. Spanish-speaking workers, however, did not think that they worked in a warm or collegial environment, and many felt like outsiders: “Most of [the people I work with] are Americans, some of them accept the Hispanic but some don’t. It’s difficult” (SW).
Participants said restaurants frequently require people to work when sick. Workers said that managers expect them to work regardless of their health: “I’ve been told to come to work when sick. . . . I just got through seeing a doctor and I had a note. ‘Well, we need you. We don’t have anyone to cover you.’ That happens all the time” (EW).
Owners said that workers often won’t mention when they’re sick because they can’t afford to miss work but also acknowledged that staffing shortages sometimes resulted in their inability to let workers stay home: “By the nature of the business, either they’re not telling you that they’re super sick because they want to work and they need to make money, or you’re under the gun and you need people to work. You’re like ‘take some Airborne and get your ass here’ ” (RO).
A major barrier to influenza vaccinations for owners and English-speaking workers was their belief that influenza vaccinations cause illness:
Owners and English-speaking workers believed that an influenza vaccination should be optional rather than mandatory and that making it mandatory would be inappropriate.
Some owners and English-speaking workers viewed influenza as something that young, healthy restaurant workers don’t need to worry about, whereas others said that getting influenza is inevitable when working with the public. For Spanish-speaking workers, the biggest barrier to influenza vaccination was being too busy working to get a vaccination.
All participants said the convenience of on-site influenza vaccination was the single most important facilitator to increasing vaccinations among restaurant workers. Many participants also emphasized the importance of offering vaccinations for free: “Obviously, I think if there was a person administering flu shots behind me right now, that’s the only way you would get staff to do it” (RO). “Some of us don’t have time to go to the doctor, or get a vaccine, because we’re at work. So if it’s accessible and it’s free, who wouldn’t do it?” (SW).
Overall, owners were positive about potentially offering vaccinations and saw it as a benefit that both workers and customers would appreciate.
Spanish-speakers generally thought of influenza as more serious than English-speakers and were more willing to pay part of the cost or go out of their way for a vaccination: “If it’s for my health I’d pay it” (SW). Survey results also supported this idea (
| Survey Question | English-Speaking Workers (n = 20) | Spanish-Speaking Workers (n = 22) |
|---|---|---|
|
| ||
| Yes | 2 | 20 |
| Yes, but only if paid for my time | 2 | 2 |
| No | 16 | 0 |
|
| ||
| Yes | 6 | 18 |
| Yes, but only if paid for my time | 5 | 1 |
| No | 8 | 2 |
| Missing data | 0 | 1 |
|
| ||
| Yes | 1 | 18 |
| Yes, but only if paid for my time | 4 | 1 |
| No | 14 | 2 |
| Missing data | 1 | 1 |
|
| ||
| I would pay full price. | 0 | 5 |
| I would pay part of the price. | 6 | 16 |
| I would not pay anything. | 14 | 1 |
Two broad themes on the owner–worker relationship emerged. First, Spanish-speaking workers strongly asserted that owners did not value or care about Hispanic workers and therefore were unlikely to offer them support in health promotion: “The supervisor would say ‘it’s your problem, I don’t care if you smoke or not’” (SW). “The idea from a Hispanic is ‘work, work, work’ . . . the employer doesn’t even know your name” (SW). English-speaking workers did not express these views. Second, although owners were concerned about intrusion and privacy, workers indicated they would be receptive if health issues were communicated appropriately.
We found that owners will support health interventions only if clear benefits to their businesses exist. Tobacco cessation and influenza vaccinations were seen as opportunities for health promotion among restaurant workers; however, physical activity interventions did not align with owner and worker interests.
Owners want to reduce tobacco use to increase productivity and improve the customer experience. Smoking breaks are a strong part of restaurant culture, and lack of enforcement of equitable breaks frustrates both owners and nonsmoking workers. Restaurant owners could limit smoking hours and enforce equitable breaks among all workers to reduce this tension. Creating smoking-break policies and providing information about tobacco quitlines could reduce tobacco use and is consistent with
Increasing physical activity is a low priority for restaurants, because workers believe they are highly active during their workday. Owners and workers think encouraging physical activity in an industry that profits from unhealthy food is an inconsistent message. Therefore, any physical activity promotion in restaurants should be combined with healthy eating interventions. Although the
This study found that workers would be likely to get influenza vaccinations if restaurants offered them on-site. Offering them free is another facilitator, especially for English-speaking workers. Because myths about influenza vaccination (eg, causes sickness, only for the elderly) are common among English-speakers, providing on-site educational materials is crucial.
Owners support influenza vaccination because it could reduce absences from work and prevent staffing shortages. We found evidence of pressure from owners for workers to work when sick. However, it was also clear that missing a day of wages is often a hardship for low-wage workers. Paid-sick-leave policies may help workers meet their own and their families’ health needs; however, low-wage workers have little access to this benefit (
Findings on Spanish-speaking workers and influenza were somewhat surprising. Hispanic populations currently fall behind non-Hispanic white populations in influenza vaccination coverage by about 10%, and some studies suggest resistant attitudes may contribute to disparities (
We found that Hispanic workers perceive that management does not value them. Language, cultural barriers, and discrimination may contribute to the divide between these groups. Worker privacy was a concern for owners, yet workers predominantly said health promotion efforts would be appropriate and appreciated. These findings are consistent with research on employer and worker perspectives in low-wage workplaces (
Limitations of this study include that it uses a small, convenience sample of sit-down restaurant workers from 1 US city. Because Seattle has a robust, progressive public health infrastructure, including a law prohibiting smoking in public places, the findings may not be generalizable to all restaurant workers. A strength of this study is that it is the first to describe perspectives of both English- and Spanish-speaking workers on workplace health promotion in restaurants. This is also the first qualitative study on feasibility of workplace health promotion among restaurant workers in the areas of tobacco cessation, physical activity, and influenza vaccination.
Tobacco cessation and influenza vaccination are areas of opportunity for health promotion in restaurants, while physical activity interventions face greater challenges. We applied these findings to a pilot study exploring on-site influenza vaccinations among restaurant workers in Seattle (
This research was supported by grant R21CA136435 from the National Cancer Institute and by the University of Washington Health Promotion Research Center, a Prevention Research Center supported by cooperative agreement no. U48-DP001911 from the Centers for Disease Control and Prevention (CDC). The findings and conclusions in this article are those of the authors and do not necessarily represent CDC’s official position.
The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions.